Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434402965
Report Date: 04/25/2018
Date Signed: 04/25/2018 12:31:16 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:FAHEEM, SAMINAFACILITY NUMBER:
434402965
ADMINISTRATOR:FAHEEM, SAMINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 323-8111
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:12CENSUS: 0DATE:
04/25/2018
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Samina FaheemTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Mel Matos met with Samina Faheem, Licensee, for an unannounced 3 year required inspection. The Licensee states that she does not have any day care children enrolled at this time. Licensee states that she is unsure if she is going to reopen her day care at this time; however, she wishes to put her license on "Inactive" status in case she elects to reopen her day care within the next year. LPA advised the Licensee that the maximum period that she can have her license on "inactive" status is one year.

LPA provided the Request for Inactive Child Care License Status form (LIC 9211) to the Licensee and the Licensee completed and signed the form during today's inspection.

The Licensee understands that she must comply with the following conditions:

1) Licensee will not provide child care for which a license is required until her license is activated.

2) Licensee will continue to promptly pay her annual license fee.

3) Licensee will inform the San Jose Regional Office of any changes in her inactive status prior to reopening her Facility.

4) Licensee will be in compliance with all licensing laws and regulations upon reopening her Facility, including but not limited to: Ensuring that all adult staff and residents have criminal record clearances, maintaining current CPR and First Aid certifications, maintaining a current fire extinguisher and functioning smoke/carbon monoxide detectors, obtaining proof of pertussis (Tdap), measles (Mmr), and flu vaccines, and completing the required mandated reporter training for child care workers.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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